Nasogastric tube (NGT) insertion and removal Nursing Procedure

Usually inserted to decompress the stomach , a nasogastric tube (NG) tube prevent vomiting after major surgery . An NG typically is in place for 48-72 hours after surgery, by which time peristalsis usually resumes.

Usually inserted to decompress the stomach , a nasogastric tube (NG) tube prevent vomiting after major surgery . An NG typically is in place for 48-72 hours after surgery, by which time peristalsis usually resumes.

The NG tube can also be used to assess and treat: Upper GI bleeding Collect gastric contents for analysis Perform gastric lavage Aspirate gastric secretions Administer medications and nutrients

Upper GI bleeding

Collect gastric contents for analysis

Perform gastric lavage

Aspirate gastric secretions

Administer medications and nutrients

Equipments needed

Equipments needed Tube (usually #12, #14, #16 or #18 French for a normal adult.

Tube (usually #12, #14, #16 or #18 French for a normal adult.

Equipments needed Towel or linen-saver pad

Towel or linen-saver pad

Equipments needed Penlight

Penlight

Equipments needed 1” or 2” hypoallergenic tape or Opsite

1” or 2” hypoallergenic tape or Opsite

Equipments needed Liquid skin barrier

Liquid skin barrier

Equipments needed Gloves

Gloves

Equipments needed Water soluble lubricant

Water soluble lubricant

Equipments needed Cup or glass of water with straw (if appropriate)

Cup or glass of water with straw (if appropriate)

Equipments needed Stethoscope

Stethoscope

Equipments needed Tongue blade

Tongue blade

Equipments needed Catheter-tip or bulb syringe or irrigation set

Catheter-tip or bulb syringe or irrigation set

Equipments needed Safety pin

Safety pin

Equipments needed Ordered suction equipment

Ordered suction equipment

Equipments needed (optional) Metal clamp

Metal clamp

Equipments needed (optional) Ice

Ice

Equipments needed (optional) Alcohol pad

Alcohol pad

Equipments needed (optional) Warm water (in the picture is a hot water bag)

Warm water

(in the picture is a hot water bag)

Equipments needed (optional) Large basin or plastic container

Large basin or plastic container

Equipments needed (optional) Rubber band

Rubber band

Preparation To ease insertion, increase a stiff tube’s flexibility by coiling it around your finger for a few seconds or by dipping it into warm water. Stiffen a limp rubber tube by briefly chilling it in ice.

To ease insertion, increase a stiff tube’s flexibility by coiling it around your finger for a few seconds or by dipping it into warm water.

Stiffen a limp rubber tube by briefly chilling it in ice.

Procedure Provide privacy, wash your hands, and put on gloves.

Provide privacy, wash your hands, and put on gloves.

Inserting an NG tube Explain the procedure to the patient. Tell her that she may experience some discomfort and that swallowing will ease the tube’s advancement.

Explain the procedure to the patient.

Tell her that she may experience some discomfort and that swallowing will ease the tube’s advancement.

Inserting an NG tube Help the patient into high Fowler’s position unless contraindicated.

Help the patient into high Fowler’s position unless contraindicated.

Inserting an NG tube Stand at the patient’s right side if you’re right-handed or at her left side if you’ left-handed to ease insertion .

Stand at the patient’s right side if you’re right-handed or at her left side if you’ left-handed to ease insertion .

Inserting an NG tube Drape the towel or linen-saver pad over the patient’s chest.

Drape the towel or linen-saver pad over the patient’s chest.

Inserting an NG tube To determine how long the NG tube must be to reach the stomach , hold the end of the tube at the tip of the patient’s nose. Extend the tube to the patient’s earlobe and then down to the xiphoid process.

To determine how long the NG tube must be to reach the stomach , hold the end of the tube at the tip of the patient’s nose.

Extend the tube to the patient’s earlobe and then down to the xiphoid process.

Inserting an NG tube Mark this distance on the tubing with tape.

Mark this distance on the tubing with tape.

Inserting an NG tube To determine which nostril will allow easier access , use a penlight and inspect for a deviated septum or other abnormalities.

To determine which nostril will allow easier access , use a penlight and inspect for a deviated septum or other abnormalities.

Inserting an NG tube Lubricate the first 3” (7.6 cm) of the tube with a water-soluble gel.

Lubricate the first 3” (7.6 cm) of the tube with a water-soluble gel.

Inserting an NG tube Instruct the patient to hold her head straight and upright.

Instruct the patient to hold her head straight and upright.

Inserting an NG tube Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patient nostril.

Grasp the tube with the end pointing downward, curve it if necessary, and carefully insert it into the more patient nostril.

Inserting an NG tube Aim the tube downward and toward the ear closest to the chosen nostril. Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.

Aim the tube downward and toward the ear closest to the chosen nostril.

Advance it slowly to avoid pressure on the turbinates and resultant pain and bleeding.

Inserting an NG tube When the tube reaches the nasopharynx, you’ll feel resistance.

When the tube reaches the nasopharynx, you’ll feel resistance.

Inserting an NG tube Instruct the patient to lower her head slightly to close the trachea and open the esophagus.

Instruct the patient to lower her head slightly to close the trachea and open the esophagus.

Inserting an NG tube Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube wont enter the patient’s mouth.

Then rotate the tube 180 degrees toward the opposite nostril to redirect it so that the tube wont enter the patient’s mouth.

Inserting an NG tube Unless contraindicated, offer the patient a cup of water with a straw. Direct her to sip and swallow as you slowly advance the tube. This helps the tube pass to the esophagus. (If you aren’t using water, ask the patient to swallow.)

Unless contraindicated, offer the patient a cup of water with a straw.

Direct her to sip and swallow as you slowly advance the tube.

This helps the tube pass to the esophagus. (If you aren’t using water, ask the patient to swallow.)

Ensuring proper tube placement Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing.

Use a tongue blade and penlight to examine the patient’s mouth and throat for signs of a coiled section of tubing.

Ensuring proper tube placement As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in bronchus and must be removed immediately.

As you carefully advance the tube and the patient swallows, watch for respiratory distress signs, which may mean the tube is in bronchus and must be removed immediately.

Ensuring proper tube placement Stop advancing the tube when the tape mark reaches the patient’s nostril.

Stop advancing the tube when the tape mark reaches the patient’s nostril.

Ensuring proper tube placement Attach the catheter-tip or bulb syringe to the tube and try to aspirate stomach contents.

Attach the catheter-tip or bulb syringe to the tube and try to aspirate stomach contents.

Ensuring proper tube placement If you don’t obtain stomach contents, position the patient on her left side to move the contents into the stomach’s greater curvature, and aspirate again.

If you don’t obtain stomach contents, position the patient on her left side to move the contents into the stomach’s greater curvature, and aspirate again.

Ensuring proper tube placement If you still can’t aspirate stomach contents, advance the tube 1” to 2” (2.5 - 5 cm). Then inject 10cc air into the tube.

If you still can’t aspirate stomach contents, advance the tube 1” to 2” (2.5 - 5 cm).

Then inject 10cc air into the tube.

Ensuring proper tube placement At the same time, auscultate for air sounds with your stethoscope placed over the epigastric region. You should hear a whooshing sound if the tube is patent and properly positioned in the stomach.

At the same time, auscultate for air sounds with your stethoscope placed over the epigastric region.

You should hear a whooshing sound if the tube is patent and properly positioned in the stomach.

Ensuring proper tube placement If these test don’t confirm proper tube placement, you’ll need X-ray verification.

If these test don’t confirm proper tube placement, you’ll need X-ray verification.

Example of a CXR showing a misplaced NG tube

Ensuring proper tube placement Secure the NG tube to the patient’s nose with hypoallergenic tape, (or other designated tube holder). If the patient’s skin is oily, wipe the bridge of her nose with an alcohol pad and allow to dry.

Secure the NG tube to the patient’s nose with hypoallergenic tape, (or other designated tube holder).

If the patient’s skin is oily, wipe the bridge of her nose with an alcohol pad and allow to dry.

Ensuring proper tube placement Apply liquid skin barrier to make the tape more adherent to the skin.

Apply liquid skin barrier to make the tape more adherent to the skin.

Ensuring proper tube placement You’ll need about 4” (10 cm) of 1”tape. Split one end of the tape up the center about 1 ½” (3.8 cm). Make tabs on the split ends (by folding sticky sides together).

You’ll need about 4” (10 cm) of 1”tape.

Split one end of the tape up the center about 1 ½” (3.8 cm).

Make tabs on the split ends (by folding sticky sides together).

Ensuring proper tube placement Stick the uncut tape end on the patient’s nose so that the split in the tape starts about ½” (1.3 cm) to 1 ½” from the tip of her nose.

Stick the uncut tape end on the patient’s nose so that the split in the tape starts about ½” (1.3 cm) to 1 ½” from the tip of her nose.

Ensuring proper tube placement Crisscross the tabbed ends around the tube. Then apply another piece of tape over the bridge of the nose to secure the tube.

Crisscross the tabbed ends around the tube.

Then apply another piece of tape over the bridge of the nose to secure the tube.

Ensuring proper tube placement Alternatively, stabilize the tube with Opsite or a prepackaged product that secures and cushions it at the nose.

Alternatively, stabilize the tube with Opsite or a prepackaged product that secures and cushions it at the nose.

Ensuring proper tube placement To reduce discomfort from the weight of the tube, tie a slipknot around the tube with a rubber band, and then secure the rubber band to the patient’s gown with a safety pin, or wrap another piece of tape around the end of the tube and leave a tab. Then fasten the tape tab to the patient’s gown.

To reduce discomfort from the weight of the tube, tie a slipknot around the tube with a rubber band, and then secure the rubber band to the patient’s gown with a safety pin, or wrap another piece of tape around the end of the tube and leave a tab.

Then fasten the tape tab to the patient’s gown.

Ensuring proper tube placement Attach the tube to suction equipment, if ordered, and set the designated suction pressure.

Attach the tube to suction equipment, if ordered, and set the designated suction pressure.

Ensuring proper tube placement Provide frequent nose and mouth care while the tube is in place. An NG tube may be inserted or removed at home.

Provide frequent nose and mouth care while the tube is in place.

An NG tube may be inserted or removed at home.

*Confirming NG tube placement When confirming NG tube placement, never place the tube’s end in a container of water. If the tube is malpositioned in the trachea, the patient may aspirate water.

When confirming NG tube placement, never place the tube’s end in a container of water.

If the tube is malpositioned in the trachea, the patient may aspirate water.

*Confirming NG tube placement Besides, water without bubbles doesn’t confirm proper placement. Instead, the tube may be coiled in the trachea or the esophagus.

Besides, water without bubbles doesn’t confirm proper placement.

Instead, the tube may be coiled in the trachea or the esophagus.

Removing an NG tube Explain the procedure to the patient and that it may cause some discomfort.

Explain the procedure to the patient and that it may cause some discomfort.

Removing an NG tube Assess bowel function by auscultating for peristalsis or flatus.

Assess bowel function by auscultating for peristalsis or flatus.

Removing an NG tube Help the patient into semi-Fowler’s position. Then drape a towel or linen-saver pad across her chest to protect her from spills.

Help the patient into semi-Fowler’s position.

Then drape a towel or linen-saver pad across her chest to protect her from spills.

Removing an NG tube Put on gloves. Using a catheter-tip syringe, flush the tube with 10ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.

Put on gloves.

Using a catheter-tip syringe, flush the tube with 10ml of normal saline solution to ensure that the tube doesn’t contain stomach contents that could irritate tissues during tube removal.

Removing an NG tube Untape the tube from the patient’s nose, and then unpin it from her gown.

Untape the tube from the patient’s nose, and then unpin it from her gown.

Please wear gloves!!!

Please wear gloves!!!

Removing an NG tube Clamp the tube by folding it in your hand.

Clamp the tube by folding it in your hand.

Removing an NG tube Ask the patient to hold her breath to close the epiglottis. Then withdraw the tube gently and steadily. (when the distal end of the tube reaches the nasopharynx, you can pull it quickly.)

Ask the patient to hold her breath to close the epiglottis.

Then withdraw the tube gently and steadily. (when the distal end of the tube reaches the nasopharynx, you can pull it quickly.)

Please wear gloves!!!

Please wear gloves!!!

Removing an NG tube Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.

Assist the patient with thorough mouth care, and clean the tape residue from her nose with adhesive remover.

Removing an NG tube Monitor the patient for signs of GI dysfunction.

Monitor the patient for signs of GI dysfunction.

Pointers If the patient has a nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary.

If the patient has a nasal condition that prevents nasal insertion, pass the tube orally after removing any dentures, if necessary.

Pointers First coil the end of the tube around your hand. This helps curve and direct the tube downward at the phaynx.

First coil the end of the tube around your hand.

This helps curve and direct the tube downward at the phaynx.

Pointers While advancing the tube. Observe for signs that it is entered the trachea, such as choking or breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without a cough reflex.

While advancing the tube.

Observe for signs that it is entered the trachea, such as choking or breathing difficulties in a conscious patient and cyanosis in an unconscious patient or a patient without a cough reflex.

Pointers If these signs occur, remove the tube immediately. Allow the patient time to rest; then try to reinsert the tube.

If these signs occur, remove the tube immediately.

Allow the patient time to rest; then try to reinsert the tube.

Pointers After tube placement, vomiting suggest tubal obstruction or incorrect position. Assess immediately to determine the cause.

After tube placement, vomiting suggest tubal obstruction or incorrect position.

Assess immediately to determine the cause.

Complications of NG intubation Although nasogastric (NG) intubation is a common procedure, it does carry risk.

Although nasogastric (NG) intubation is a common procedure, it does carry risk.

Complications of NG intubation (Long-term concerns) Potential complications of prolonged intubation includes: Esophagitis Esophagotracheal fistula Gastric ulceration Pulmonary and oral infection Sinusitis Skin erosion at the nostril

Potential complications of prolonged intubation includes:

Esophagitis

Esophagotracheal fistula

Gastric ulceration

Pulmonary and oral infection

Sinusitis

Skin erosion at the nostril

Complications of NG intubation (Suction reactions) Additional complications include: Electrolyte imbalances Dehydration

Additional complications include:

Electrolyte imbalances

Dehydration

Complications of NG intubation (Suction reactions) Vigorous suction ,ay damage the gastric mucosa and cause significant bleeding, possibly interfering with endoscopic assessment and diagnosis.

Vigorous suction ,ay damage the gastric mucosa and cause significant bleeding, possibly interfering with endoscopic assessment and diagnosis.

Using an NG tube at home If your patient will have a nasogastric (NG) tube in place at home, find out who will insert the tube. If he will have a home care nurse, tell him to expect her.

If your patient will have a nasogastric (NG) tube in place at home, find out who will insert the tube.

If he will have a home care nurse, tell him to expect her.

Using an NG tube at home Make a list; check it twice If the patient or a family member will perform the procedure, you’ll need to provide additional instruction and supervision.

Make a list; check it twice

If the patient or a family member will perform the procedure, you’ll need to provide additional instruction and supervision.

Using an NG tube at home Use this checklist to prepare teaching topics: How and where to obtain equipment needed for home intubation. How to insert the tube.

Use this checklist to prepare teaching topics:

How and where to obtain equipment needed for home intubation.

How to insert the tube.

Using an NG tube at home How to verify tube placement by aspirating stomach contents. How to correct tube misplacement. How to prepare formula for tube feeding. How to store formula, if appropriate.

How to verify tube placement by aspirating stomach contents.

How to correct tube misplacement.

How to prepare formula for tube feeding.

How to store formula, if appropriate.

Using an NG tube at home How to administer formula through the tube. How to remove and dispose of an NG tube. How to clean and store a reusable NG tube.

How to administer formula through the tube.

How to remove and dispose of an NG tube.

How to clean and store a reusable NG tube.

Using an NG tube at home How to use the NG tube for gastric decompression, if appropriate. How to set up and operate suctioning equipment. How to troubleshoot suctioning equipment. How to perform mouth care and other hygenic procedures.

How to use the NG tube for gastric decompression, if appropriate.

How to set up and operate suctioning equipment.

How to troubleshoot suctioning equipment.

How to perform mouth care and other hygenic procedures.

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All rights reserved 2008 “ Nurses Informations”

All rights reserved 2008

“ Nurses Informations”